Info Center

Heart Failure: 21st Century Epidemic

Heart failure is one of three cardiovascular epidemics of the 21st century — the
others being atrial fibrillation and diabetes mellitus with its attendant
cardiovascular disease.
More than five million Americans are living with heart failure, with an additional
half a million people being diagnosed each year. More Medicare dollars are spent for
heart failure diagnosis and treatment than any other disease. While heart failure is a
long-term clinical disorder, the availability of patient education and significant advances
in pharmacologic and device therapies have significantly improved outcomes.
Recently, Healthy Living magazine assembled three Eisenhower Medical Center
experts to discuss the roles of clinical intervention and education in improving the quality
of life of patients with heart failure. The participants were Leon Feldman, MD, Board
Certified Cardiologist/Electrophysiologist, Mary Jo Killen, RN, BSN, Glickman Heart
Failure Clinic, an Eisenhower Medical Center facility located in the Renker Wellness
Center, and Philip Shaver, MD, Board Certified Cardiologist, who served as moderator.

DR. SHAVER: Many of our readers may
be familiar with the term “congestive
heart failure” and may not realize that
the term “heart failure” is now preferred.
While congestion in the lungs and fluid in
the legs are common symptoms of heart
failure, they are not always present, so
the modifier “congestive” has been
removed.

DR. FELDMAN: Heart failure isn’t a single
disease, but a constellation of symptoms,
including weight gain, fluid retention,
breathlessness, fatigue, and malaise.
Fundamentally, the heart is not working
efficiently and the body can’t handle fluids
normally. But we’re really talking about a
number of diseases, and as you say,
congestion does not necessarily have to be
a component.

DR. SHAVER: Heart failure is a complex
clinical disorder. A very simple definition
is that the heart is not adequately
supplying blood flow, and the symptoms
you mentioned are the body’s way of
compensating for that inefficiency.
Statistics have shown that we’re seeing a
decrease in mortality from heart attacks,
but more people are suffering from heart
failure. Leon, why do you think this is
happening?

DR. FELDMAN: Overall, we’re treating
heart disease more effectively and there are
fewer deaths from heart attacks. But the
fact that our patients live longer gives them
time to develop more complications.

DR. SHAVER: Our population is aging,
which is a key risk factor. Eighty percent
of the patients hospitalized with heart
failure are over 65 years of age.
“Heart failure is a longterm
disease, so treatment
has to be done on a longterm
basis…Education
about this process is
incredibly important in
order for the patient to
understand that the longterm
outcomes are good.”

DR. FELDMAN: We have come to
understand that the human body has
many mechanisms to survive short-term
traumas. In the case of heart failure, when
the blood flow from the heart is insufficient,
the body compensates, trying to retain salt
and water to increase cardiac output to
supply adequate blood flow to the organs.
This works well for short-term survival, just
as it did in early man, but those same
mechanisms are damaging long-term.We
know that tackling short-term solutions and
then allowing the body to recover by
minimizing things such as salt and water
retention has improved heart failure
outcomes.

DR. SHAVER: Minimizing salt intake is
important for heart failure patients. Mary
Jo, are patients surprised to learn which
foods are high in sodium?

MARY JO: Absolutely. Even I was surprised
to learn low fat cottage cheese has about 800
milligrams of sodium in one cup. Heart
failure patients should avoid most canned
soups, and really most processed foods,
though some are getting better. Cheeses,
salad dressings, vegetable drinks and sports
drinks are all high in sodium. It’s very
important to learn to read the labels for
sodium content and find healthier
alternatives.

DR. SHAVER: For many years, diuretics
were our first line of defense against heart
failure. Unless the patient is actually
retaining fluid, that’s really not the case
anymore. What’s your preferred regimen,
Leon?

DR. FELDMAN: The problem with diuretics
is that they can be harmful over the long
run, so they’re not so much in favor
anymore. Now we tend to use beta blockers,
which block adrenaline. Adrenaline is very
harmful, and beta blockers let the heart rest
and heal. The bottom line is that heart
failure requires long-term treatment.

DR. SHAVER: Patients are often sensitive
to beta blockers, sometimes feeling worse
before they feel better. I find that staff
specially trained in heart failure
management, such as the nurses in the
Glickman Heart Failure Clinic, can help
patients work through that adjustment
period of the dosage.

DR. FELDMAN: Heart failure is a long-term
disease, so treatment has to be done on a
long-term basis.We’ve discovered that if you
use beta blockers gradually, making small
increases to the dose every few weeks to a
month, patients tolerate them better.
Education about this process is incredibly
important in order for the patient to
understand that the long-term outcomes
are good.

DR. SHAVER: We also use ACE inhibitors —
angiotensin receptor blockers. When Mary
Jo sees a patient at the Glickman Heart
Failure Clinic, it’s common for the person
to have five or six medications at least —
aspirin, statins and ACE inhibitors are a
few of them. Mary Jo, explain how you
assist heart failure patients at the clinic.

MARY JO: Our primary goal is to educate
—both our own patients and anyone in the
community who is concerned about heart
failure.We tell them to watch for a variety of
symptoms and to call the clinic for shortness
of breath, fatigue, swelling of their lower
extremities, three- to five-pound weight gain
in a week or being unable to breathe when
lying flat.We also review medications and
adjust dosages per their cardiologist’s orders.
Being vigilant on all of these fronts can help
keep patients out of the emergency room.

MARY JO:We have a support group open to
anyone in the community that meets the
thirdWednesday of every month.We also
offer lectures by health professionals,
whether it’s a cardiologist discussing high
cholesterol, hypertension, or the latest
treatment in heart failure, or a pharmacist
explaining over-the-counter drugs, or a
physical therapist discussing exercise.We also
have a weekly class called Living with Heart
Failure and monthly nutritional classes.

DR. SHAVER: Mary Jo, do your patients
ask you about exercise?

MARY JO: Yes, they do. Exercise is very
important, and often it can make the heart
more efficient. It also makes patients feel
better mentally and physically, and more
energetic. Exercise in the pool is particularly
good. Heart failure patients can also use two
pound weights, even while they’re sitting in
a chair, to exercise their limbs. Of course, I
always tell patients to check with their
physician for a recommendation.

DR. SHAVER: Medication is not the only
way to approach heart failure. We should
also talk about device therapy, or nondrug
therapy, for heart failure.

DR. FELDMAN: Heart failure patients are at
risk for developing life-threatening heart
rhythms. Those with weak heart muscles
should be considered for an implanted
defibrillator, particularly patients whose
heart function or ejection fraction is less
than 35 to 40 percent. Ejection fraction is a
measurement of how well the heart
contracts. This percentage is easily obtained
noninvasively by cardiac ultrasound,
commonly referred to as an
echocardiogram.

DR. SHAVER: The echocardiogram really
is a critical tool for heart failure patients,
because their hearts are weak and don’t
contract well. Leon, would you please
describe the role of biventricular pacing
for hearts in this condition?

DR. FELDMAN:When patients don’t
respond well to medication, we often
evaluate them for a pacing device to help
the heart contract better. This is called
biventricular pacing. It’s about an hour-long
procedure in which a specialized pacemaker
is placed with two or three wires. This
“paces” both lower chambers of the heart,
allowing it to contract more uniformly and
more forcefully.

DR. SHAVER: What’s the difference
between that and a standard pacemaker
used to treat a slow heart rate?

DR. FELDMAN: A standard pacemaker
ensures the heart rate doesn’t slow down
too much; it’s about keeping the heart at a
particular rate. It paces about half the heart
and is usually effective. However, in heart
failure patients, we need to pace most of the
heart, and that’s where biventricular pacing
comes in. The extra wires stimulate the
whole heart muscle so that it contracts more
strongly. Biventricular pacing is a means of
restoring efficiency to improve the blood
flow.

DR. SHAVER: So biventricular pacing is
more beneficial for a patient with weak
heart muscles.

DR. FELDMAN: A standard pacemaker can
make the heart even weaker in patients with
weak heart muscles because the heart now
contracts in a more disorganized way —
first one chamber of the heart and then the
other. The goal is to have all chambers of
the heart contract in a symmetrical way.

DR. SHAVER: Leon, there are also devices
that patients can use at home for remote
monitoring of their condition.

DR. FELDMAN: Remote devices can help
evaluate a patient’s current condition and
also predict their progress over the next few
weeks or months in an effort to avoid
hospitalization if possible. One company’s
approach is to provide a blood pressure cuff
and a scale that work on Bluetooth®
technology, just like cell phones.

DR. SHAVER: The device can measure and
look for accumulation of fluid in the
lungs?

DR. FELDMAN: Patients take their blood
pressure and weigh themselves on a daily
basis, and when either measurement gets
out of range, the device automatically
notifies the physician that the patient’s
condition is changing. In addition, there
is technology that works with the
biventricular pacing devices and
defibrillators to measure resistance in the
chest. The more fluid in the chest, the lower
the resistance. This device can also notify
the doctor that the patient may be retaining
fluid.

DR. SHAVER: I think that these kinds of
advanced monitoring systems are going to
be a major improvement in how we treat
our heart failure patients. It provides an
enormous sense of security for patients
and improves their quality of life.

DR. FELDMAN: Absolutely. Patients request
remote monitoring now.

DR. SHAVER: Any physician on staff at
Eisenhower can refer a patient to the
clinic — a cardiologist, internist or family
practice physician, for example. How does
the staff at the Glickman Heart Failure
Clinic interact with the primary doctor,
Mary Jo?

MARY JO: On the day we see a patient, we
provide notes to the referring physician
about the patient’s visit, any lab work that
was done and any changes we made.

DR. SHAVER: Finally, I’d like to mention
some additional resources. Readers
interested in the Glickman Heart Failure
Clinic can call 760-773-2080. A Web
site that explains all of the medications
being used for heart failure is
www.chfpatients.com. I also strongly
recommend the Heart Failure Society of
America site (www.hfsa.org).